Last summer, Steve Pantilat, MD, was interviewed by GeriPal, a blog (geripal.org) that focuses on geriatric medicine. Dr. Pantilat is a palliative care physician at UCSF. The interview occurred shortly after his book was published — “Life After the Diagnosis: Expert Advice on Living Well with Serious Illness for Patients and Caregivers.”

We posted a link to the podcast of the interview on Brain Support Network’s Facebook page at the time, but I just got around today to listening to the podcast. Here’s are some highlights for me:

* “There’s this idea that somehow if we talk about what’s really happening, like how serious your prognosis is, or the fact that you have in fact a life limiting illness, that somehow that’s gonna take away hope and so, let’s not talk about it, we need to leave people with hope. But I worry that what that leaves people with is false hope. And that fundamentally, false hope is no hope. And if we talk about hope, we can really promote it and we can encourage it and to recognize that people have hope, even when we take care of people who are days away from the end of life, who are actively dying. They still have hope for things that are meaningful to them. And by talking about it, we can really encourage people to have hope, and to build on and to recognize, yeah, there’s hope for cure, sure. But there’s hope for a lot of other things that can coexist within the hope for cure, or alongside that hope, and we can encourage that.”

* “[We] talk about a good death but I don’t see death as good. I’ve seen it only as being sad and filled with grief and loss, and nothing we do seems to make it good. And the tragedy … I recently took care of a forty-two-year-old woman with an eight-year-old child in the hospital. She died in the hospital. People would say, ‘Oh, that’s a bad death,’ but you know, what was bad is that she died. And if she had died at home, it wouldn’t change the tragedy and the sadness and the grief and loss associated with her death.”

* The interviewer mentioned a story in the book about Sergei, an 80-year-old whose wife has dementia. Sergei hopes that the wife will get better. The interviewer asked Dr. Pantilat if this is false hope. “That I would say is false hope, we know that dementia does not reverse. …I realize that there was nothing I could say that would fundamentally change his hope in his wife getting better and I realize my role at that point was just to support him in that hope. … But, you know, there’s a time to push and there’s a time to accept and support and that was a time to accept and support.”

* “Realistic prognosis focuses hope. They give patients reliable and realistic information they can use to make decisions.”

* “[We] often give people this false choice, we say, ‘Do you want quantity of life or quality of life?’ And it’s somehow, if you want quantity of life, you have to accept all the possible interventions to attack your illness or to treat your illness. Every chemotherapy regimen, every procedure, and so on. And what we know now is that, in fact, there comes a time when some of those things not only don’t help you live longer but may actually ruin your quality of life. Chemotherapy in the last six months of life, for example. And that somehow if you want quality of life, it means you’re not gonna live quite as long. And what we know from Palliative Care, from the research, from the literature in our field, is that you can get both. And Palliative Care helps you live better and at least as long, maybe longer, but certainly no shorter, and you can live well and long. And part of my book, the point is to really get people to engage with and ask for and demand Palliative Care to live well and to live long.”

* He talks about using a word like “progress.” “Like progressive illness, your illness has progressed. ‘Oh, that’s great!’ No, that’s terrible. So I now think about this when I talk with my patients and I say, ‘Your heart failure is worse,’ rather than saying, your heart failure has progressed…”

* “Dignity is one of those very loaded words that’s in fact very personal. … And so we often use this word as a code for certain things. Like, respect your dignity by withdrawing interventions and what we should … If we’re gonna use that word, we [physicians] really need to embed it in what the patient and family think of as dignity and their interpretation of dignity and try to support that idea, not our own.”

* “If despite CPR, you die, your final moments will have been spent at the center of a tornado and while a team works on your body, your family will be watching the horror or be banished from the room. In either case, they won’t be with you, at your side, holding your hand.”

* “I think there’s a way in which people with serious illness think, ‘Why not? Why not just try it?’ And the evidence really suggests that when your illness is very advanced, to the point that you die of it, CPR isn’t really gonna help you. It’s not gonna help you at all and you’re gonna end up sicker. I think there’s a way that people think it’s like reset the computer. … But we all know that even if you survive CPR, you’re gonna be worse off than you were and there are implications, maybe not for you, I think this idea that somehow it’s suffering for the patient, I think is not right. We do CPR generally on people who have died. And so I don’t see that there’s a lot of added suffering to the person who’s died but there is this impact on their loved ones who might be at the bedside. And we have to remember what their experience is as well.”

* “[We] have to be careful to remember that all we’re saying is, ‘When you die, when your heart stops and you stop breathing, we will not try to revive you because it won’t work. We’ll let you die peacefully.’ But that has no bearing on all the other care that we will continue to provide. And we have to emphasize what we’ll continue in the meantime and all the care we will provide to make sure people are comfortable and well cared for so that we don’t see this decision about CPR at the very end as somehow implicating something more than it is.”

This recent New York Times (nytimes.com) article is about the idea that the typical advance care directive doesn’t say much about dementia. A physician recently developed a dementia-specific advance directive, which you can find here:

On Tuesday, January 16, 2018, the NBC TV show “Chicago Med” had a story that included a woman with progressive supranuclear palsy (PSP). The same woman had appeared in a previous episode where some details were given of PSP. In last week’s show, the patient had pneumonia. There was lots of discussion of a do-not-resuscitate (DNR) order and being placed on a ventilator. The patient died.

One person on an online support group said that last week’s TV show gave her a good opening to discuss pneumonia, end-of-life treatment, and the topic of a DNR with her spouse with PSP.

There was also some discussion online about how the lady with PSP had no problems with cognition, speech, or her eyes.

“In 2014, Talbert was diagnosed with progressive supranuclear palsy, or PSP, a rare and fast-acting neurodegenerative disease… She soon began making preparations. She knew she wanted to leave her children and grandchildren recordings of her voice — when Talbert’s father died nearly 40 years ago, that was the thing she forgot first. … She found SafeBeyond about a year after being diagnosed. It’s one of a growing number of services, including DeadSocial and GoneNotGone, that allow people to posthumously send video, audio, and text-based messages to their loved ones at planned times.”

The article notes that many find such messages comforting while others feel like such messages are “an ambush.” (Note that the “DMs” in the title refers to “direct messages.”)

This is a thought-provoking discussion of doctor-patient interaction that may benefit everyone in our network.

Many people have heard of Paul Kalanithi, who wrote “When Breath Becomes Air,” while being treated for stage IV metastatic lung cancer at the end of his training as a neurosurgeon at Stanford. He died just before finishing the book. His wife Lucy (also a Stanford physician) wrote the epilogue to complete the book. During the writing of the book, he was both doctor and patient, and Lucy was both doctor and caregiver. This summer, Lucy Kalanithi discussed the book and her thoughts on doctor-patient interaction with the dean of the Stanford School of Medicine.

Thank goodness for Brain Support Network volunteer Denise Dagan who watched the lecture and took notes! See below. Denise recommends both “When Breath Becomes Air” as well as “Being Mortal” (different author).

There’s also a good, short Stanford Medicine article — that contains lots of quotations from Lucy — about the conversation here:

Lucy shares some memories of interactions with medical professionals throughout Paul’s treatment and reflects on the doctor-patient interaction from both sides of that coin.

For example: Lucy was taught in medical school about the statistical correlation between a patient’s positive interaction with their medical team and adherence to prescribed therapies and medications. Now, she has a personal sense of the magnitude of trust that develops when you, as a patient, feel true empathy from your medical team.

Conversely, there was an incident in the hospital during which Paul felt the resident on duty was ignoring Paul’s request to add a cancer fighting drug to Paul’s medication list, so Paul took a dose from a stash in Lucy’s purse until he had time to discuss the issue farther with his medical team. Lucy understood from that experience that patients in the hospital feel imprisoned, vulnerable and powerless. They both knew taking medications not on the prescribed list was against patient safety rules and disrespectful to the resident on duty, but from the patient’s point of view, they had to do what they had to do to look out for their own best interests.

Paul wrote about a fellow doctor who committed suicide after the death of a patient. Stanford is becoming a leader in mental health care of medical staff and what measures they can implement to support stressed staff, minimize stigma over mental health issues and prevent burnout. Mindfulness, sleep hygiene, social connection and other self help measures are being discussed and made available to employees. It is exactly the same recommendations given to family caregivers to prevent burnout!

Paul was a humanities student before developing an interest in the physical nature of human beings and our mortality. He pursued that line of thinking by attending medical school. Lucy has come to agree with Paul that one cannot understand the nature of being a physical being and one’s mortality with scientific or medical facts and figures. She feels that Paul’s background in literature and philosophy gave him the best foundation to come to grips with his untimely illness and death.

Paul wrote “When Breath Becomes Air” for their daughter, who is now 3. Lucy has built upon that will for their daughter to have a connection with her father by putting together photos and stories, and having experiences with their daughter that she and Paul talked about doing together as a family.

Especially with the increased complexities of delivering care, it really must be a calling because there are easier jobs. This brought to Lucy’s mind her thinking in medical school that she was seeing more at her young age than most people will ever see with respect to the human condition. Paul’s humanities background really gave him a leg up in empathizing and communicating with patients the complex scientific details of their diagnosis and treatment options.

Lucy’s definition of empathy begins with really understanding what the other person is feeling. Sometimes, that is just naming what is happening or what they appear to be feeling, then waiting in the silence for the other person to respond. This can get the conversation to what needs to be spoken really quickly although it isn’t easy to sit with you own discomfort while they come to their response.

When she worked at Kaiser management found doctors could increase patient satisfaction by 20% just by asking, “How is this affecting your day-to-day life?” which is an empathetic question. The flip side is also true. If your medical team is not being empathetic, or is not giving you straight up information you need, tell them you prefer to know the whole truth. It will make them feel more comfortable being direct, and they will be more likely to speak with you in that manner.

At time stamp 30:00 they switch to a Q&A format. Lucy begins to speak about her personal life.

Lucy shares that her career is in a different place because of all the public speaking she’s being asked to do and dating somebody new (which was Paul’s wish), that there is a certain amount of uncertainty she learned to live with during Paul’s illness that is serving her well now that there is a different kind of uncertainty in her life.

The way we think about end of life care with all the technology that is available is as confusing for medical professionals as everyone else because, as a medical professional you have more understanding about what can be done, but there is still the question of should it be done. Communicating that well to patients is difficult because individual values come into play for the patient, doctors and each member of the patient’s family. Lucy brings up “Bring Mortal,” which discusses these issues so very well.

End of life care is where both the business case and moral case for being prudent about the 18% of GDP that is healthcare expenditures in the US.

An audience member asked Lucy to talk about how Paul’s faith was challenged during his illness and how that may have changed his approach to his patients.

Lucy doesn’t believe Paul’s faith was challenged during his illness. He would have called himself a Christian. That label impacted his perspectives on forgiveness, service to others, etc. Having a ‘good death’ has something to do with whether you feel you led the life you wanted to live. Paul had a ‘good death.’

An audience member asks if her conception of happiness evolved over the course of Paul’s disease and is it part of the human experience for a disease to do that? To the first part of the question, the answer is yes. There’s a difference between happiness and meaning. The most meaningful things involve some element of pain. Lucy used to want to be happy and I want to raise a happy kid. Her perspective has changed to wanting to have meaning in her life and raise a resilient kid. This change was illuminated through Paul’s illness, but Lucy doesn’t believe it has to be an illness that helps you find meaning, but persevering through any difficult experience or sharing someone else’s pain or struggle can help you find meaning.

An audience member who’s a physician’s assistant (PA) student asks Lucy about the relationship Paul had with a beloved nurse practitioner during his treatment and Lucy’s work with advance practice providers. Lucy is an attending in Express Care (outpatient urgent care) where she works with MDs, NPs, and PAs. She relies on all of them as different aspects of the medical care team in that setting. She also believes NPs and PAs have a tremendous role to play in primary care around the world. During Paul’s care she relied tremendously on people in those roles, One NP told Paul she really had hoped he would be one of those patients who was in their oncology clinic for seven years, but he just wasn’t going to be. Even when she was delivering terrible news, because it came from her and they knew she really cared about him/them, it was the best way to get terrible news.

An audience member asked how it was being a doctor and caregiver (and patient) at the same time. Lucy felt dependent on Paul’s health care providers as neither of she nor Paul are oncologists, but they also felt they communicated well the medical team that they understood the risks and benefits of various procedures and treatments and were willing to take the risk by either taking advantage of an option or by passing on an option.

“Palliative care” is probably a topic more people should know about. Brain Support Network volunteer Denise Dagan attended a panel on palliative care last month in San Mateo. The panel of five palliative care practitioners was sponsored by Seniors At Home and Peninsula Temple Beth El. These are Denise’s notes from the panel discussion.

Robin

Notes by Denise Dagan, Brain Support Network Volunteer

Palliative Care Panel
October 26, 2017
San Mateo, CA

The five panelists introduced themselves and made brief personal statements.

#1 – Rabbi Dennis Eisner began by encouraging everyone who hasn’t already, to share their personal wishes for end of life care before a crisis occurs. It not only reduces stress in the moment, but better ensures that what you expect to happen at the end of your life, is what actually does happen. After attending a talk by the author of “Being Mortal,” a book which talks about expectations for end of life care, he realized it was time to talk with his own mother since she had been diagnosed with cancer. He wanted to ensure she understood that treatment was not obligatory and that he would support whichever choice she made. He explained that palliative care is both medical and philosophical (spiritual, emotional, etc.) and that those extra levels of care (pain management, comfort care, spiritual and emotional support) are usually something people want when they are terribly ill.

#2 – Gary Pasternak is a hospice and palliative care doctor with Mission Hospice. He doesn’t like the term palliative care. Even though it is accurate (palliation means to ease suffering), he prefers the term Compassionate Care. At Mission Hospice and Home Care, palliative care and hospice both operate as teams of psychologists, social workers, doctors, nurses, physical therapists, occupational therapists, clergy and volunteers to address every need their patients have. Palliative care can be introduced to a family through the emergency room, intensive care unit, oncology, etc. to help a patient deal with the difficulties that come with serious illness. Doctors are often the center of the palliative care team to drive a treatment plan and either help a patient recover or manage a chronic illness. It is separate from hospice, which is is reserved for those with a prognosis of six months or less to live. It is Dr. Pasternak’s experience that death and dying issues are usually non-medical. In hospice, nurses, clergy, social workers, and volunteers do most of the patient and family support.

#3 – Redwing Keyssar is the Director of Palliative Care at Jewish Family and Children’s Services in San Francisco. Just as midwives guide a child into this world, she views herself as a midwife to the dying, guiding them out of the world. She’s been drawn to this work since the age of 30 when her best friend died. At the time (34 years ago) palliative care was a new thing. She explained that Jewish Family and Children’s Services is not a medical model, but a social service agency focused on palliative care. They are able to put services in place to ease the burden of caregiving for a serious illness. They have an annual volunteer training in the fall with so much interest enrollment fills quickly.

#4 – Gwen Harris is a geriatric care manager for Seniors at Home Palliative Care Program. She spoke about how her father was 60 years old when Gwen was born and died with she was 30. It ignited an interest in helping those suffering from long-term illness and the study of death and dying.

#5 – M.K. Nelson is Director of Spiritual Care at Mission Hospice. She shared that, sadly, while there are excellent Palliative care programs around the bay area (CA and nationally), not all have a chaplain on staff. She feels clergy has a unique perspective and comforting presence and can be very beneficial in palliative care. If you happen to have more than one palliative care program to choose from, it may be important for you to consider whether there is a chaplain available to patients and their family.

Following everyone’s introductory statements the panelists began to take questions from attendees.

Q. How do you find palliative care?

A. You can request a consult in your clinic or hospital with the palliative care team. It does not commit you to enrolling in palliative care, but a conversation with them can help you clarify your medical options while getting an overview of what palliative care has to offer in your situation.

A. Another way to ensure you have palliative care offered to you at the end of life is to codify it into instructions for your healthcare power of attorney and in your advance healthcare directive.

One way to learn about this is through Kaiser’s Life Care Planning: lifecareplan.kaiserpermanente.org/discover/. You don’t have to be a Kaiser patient. It gives you a framework for discussion and planning.

A. Start by asking your doctor for palliative care services or that you need contact information for palliative care options. If your doctor is unresponsive, look for a palliative care department phone number in your clinic or hospital directory. Failing that, hire a geriatric care manager to help you access palliative care resources.

Q. Are palliative care and hospice care connected?

A. Yes, palliative care and hospice care continuity is an excellent way to benefit from supportive services for long term or critical care illnesses. A patient would be transferred to hospice if their health gets to a point where curative treatment is no longer an option and the prognosis is six months or less. Sometimes, patients improve or stabilize and they are discharged from hospice. Many hospice programs offer a transitions or palliative care program to support them until their condition deteriorates further and they, again, qualify for hospice. Some people are in and out of hospice for years.

Q. What kind of support can I expect from palliative care?

A. Palliative care services vary from one hospital or clinic to another. Don’t feel you are being pushy if you ask for the kinds of services you feel you need or deserve. For example, often times patients are discharged from the hospital and family members are expected to perform medical tasks they neither feel comfortable doing, nor the time to do if they are working full time. It is not unreasonable to push for help in arranging for a qualified medical person to take responsibility for these tasks.

Some programs, like Sutter Health, has the AIM (Advanced Illness Management) program to help families organize services to care for their loved one, but in other areas of the bay, state of country, you may have to create a patchwork of resources to meet the demands of caring for an illness at home. In that situation, it is often beneficial to hire a geriatric care manager (which JFCS has on staff) to take on the task. Geriatric care managers know what resources are available and what questions to ask. They can take on the entire burden of care for your family member and keep it all organized.

Q. What if the primary caregiver doesn’t want strangers in their house so the patient can’t benefit from these additional services until the caregiver literally needs medical attention, themselves, from caregiver burnout?

A. Recruit your doctor or clergy to encourage hiring help into the home. Have them really play it up as a requirement. Then, start with baby steps by hiring someone to come in just one or two days weekly. Have the hired caregiver do something particularly helpful or something the caregiver or patient really dislikes having to do, themselves.

There followed an extensive conversation about the need to educate both within the medical field, the community, patients and families about palliative care. The education is happening. Terms such as person-centered care and whole-person care are being bandied about as demand for this is consumer driven. This is exactly how hospice started in England in 1948, and it is now available world wide.

Redwing Keyssar and Gwen Harris host ‘death dinner parties’ for families to have those difficult conversations. They bring advance healthcare directives for family members to fill out. There are, actually, several similar ways to open a dialog about end of life wishes:
deathoverdinner.org
http://deathcafe.com
http://www.gowish.org

Redwing left us with one final thought, “Expertise can cure some things, but it is compassion that does the healing.”

This recent New York Times article contains some do’s and don’ts about expressing sorrow for someone’s loss. The experts review these topics:

* digital condolences (social media and email)
* getting started (don’t procrastinate)
* draw on your memories (“share a memory of the person who died with the bereaved”)
* offer concrete ways to help
* what not to say (don’t refer to your own experiences with death)
* the importance of reaching out

This is a good article from today’s “Washington Post” (washingtonpost.com) on why people may not complete a living will. The author makes the point that even if you don’t have a living will, everyone (healthy or not) should designate in writing a healthcare proxy and, ideally, have a discussion with the proxy about end-of-life wishes.

Here are some excerpts from the article:

* Even though advance directives have been promoted for nearly 50 years, only about a third of U.S. adults have them, according to a recent study. People with chronic illnesses were only slightly more likely than healthy individuals to document their wishes.

* “Many people don’t sign advance directives because they worry they’re not going to get any care if they say they don’t want” cardiopulmonary resuscitation, said the study’s senior author, Katherine Courtright, an instructor of medicine in pulmonary and critical care at the University of Pennsylvania. “It becomes this very scary document that says, ‘Let me die.'”

* That’s where the health-care proxy comes in. Just naming someone isn’t enough, though. To be effective, people need to have conversations with their proxy and other loved ones to talk about their values and what matters to them at the end of life.

This personal story about the author’s terminally ill mother illustrates the importance of making your end-of-life wishes known and legally supported.

Excerpt:

When—just a few days after her eighty-ninth birthday—my mother was diagnosed with a colorectal mass (we would later learn it was cancerous), she restated to me what I long knew to be her fervent wish: no treatment of any kind beyond symptom relief. NO invasive procedures, NO chemo or radiation, NO life-prolonging treatments. NONE! She wanted only one thing: to spend the rest of her days, however many or few there were to be, in her apartment in her lively and supportive community. My job was simply to help make sure her wishes were honored. As it turned out, this was not so simple at all. Just days after the initial diagnosis, despite my mother’s long-standing, clearly stated, and just-repeated wish, I found myself reluctantly making an appointment for a preoperative examination with a surgeon for a procedure to reroute her intestine around the mass. How had we ever come to even consider this?

Today, I came across the website Option B (optionb.org), which is focused on resilience. The website’s tag line is: “Resilience is like a muscle. We’re here to help you build it.”

There’s a thought-provoking article from April 2017 by Arianna Huffington about the need to embrace grief. She writes:

“There are few things that test our resilience more than the death of a loved one. Grief can be isolating and grueling and feel insurmountable. But it’s also true that there is nothing that can teach us more about life than death. And when we allow ourselves to receive the lessons that death can teach us, we’ll be more resilient when facing whatever challenges life brings us.”

“Alien limb phenomenon” is involuntary activity of a limb and a feeling that the limb is foreign. This symptom can occur in corticobasal degeneration. Learn more about CBD.

A person’s autonomic system controls automatic functions of the body including blood pressure, heart rate, sweating, bladder emptying, sexual functions, etc. Autonomic dysfunction is an extremely common symptom in multiple system atrophy and less common in Lewy body dementia. Learn more about MSA. Learn more about LBD.

The four main motor symptoms of parkinsonism are bradykinesia (slowness of movement), rigidity, rest tremor, postural instability and gait dysfunction. Learn more.

Dementia is an umbrella term describing cognitive and memory symptoms. The most common disorder with dementia symptoms is Alzheimer’s Disease. The next two most common disorders with dementia symptoms are Vascular Dementia and Dementia with Lewy Bodies (DLB). Most researchers think Vascular Dementia is second, but some argue for DLB. Learn more.

“Fluctuating cognition” is when there are unpredictable changes in someone’s level of cognition and attention. This symptom is common in Lewy body dementia. Some families describe it as the person seems normal one minute and then something is clearly wrong the next. This is different from sundowning, which occurs predictably when the sun goes down. Learn more about LBD.